Management of tracheostomies in the intensive care unit: a scoping review

Abstract

ObjectivesWhile there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.DesignScoping review of the literature.Data sourcesPubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.Eligibility criteriaWe included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.Data extraction and synthesisTitles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.Results6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.ConclusionsThe limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.

Cuidados de enfermagem como gestão de qualidade ao usuário com traqueostomia - revisão integrativa

“…Analisou-se em um dos estudos que fornece orientações sobre a seleção do tubo de traqueostomia ideal, o uso de dispositivos de comunicação, como válvulas de fala, o uso de pacotes de cuidados diários (Bundles), troca da traqueostomia, umidificação, tempo de alimentação e cuidados com a limpeza da pele periestoma podem interferir na diminuição do tempo de permanência hospitalar, readmissões de crianças com TQT por VM e redução de complicações (Volsko, et al 2021), (Whitmore, et al, 2020).…”

An Overview of Outcomes Associated With Early Versus Late Tracheostomy From a National Standpoint

“…It is most often used in patients who have had trouble weaning off a ventilator, intending to ease weaning by reducing work of breathing in patients with reduced reserve, to protect the vocal cords from damage induced by an endotracheal tube passing between them and exerting pressure on vocal cords, reducing the need for sedation, and its associated negative effects on blood pressure and gut function, and allowing for earlier patient mobilization, absorbing gastrointestinal feeds, and physical and occupational therapy [ 6 ]. In between 10% and 15% of patients admitted to intensive care units, a tracheostomy is performed [ 7 ]. While it is usually carried out between days 10 and 14 of intubation, the optimum timing of a tracheostomy has yet to be determined by evidence-based practice [ 8 ].…”

Association between tracheostomy timing and outcomes for older critically ill COVID-19 patients: prospective observational study in European intensive care units

“…In patients who are expected to require prolonged mechanical ventilation, tracheostomy has several advantages, including reduced work of breathing, easier suctioning, reduced risk of accidental extubation, improved rehabilitation, oral hygiene and patient comfort. 7 To date, the optimal timing of tracheostomy has not been established. The evidence on mortality benefit from early tracheostomy is conflicting, with a significant variation in the direction and magnitude of effect between studies that assessed outcomes of patients requiring tracheostomy using different lengths of follow-up period.…”